Carotid endarterectomy (CEA) is a surgical procedure used to reduce the risk of stroke from carotid artery stenosis (narrowing the internal carotid artery).. Will CREST 2 demonstrate any value of CEA or CAS over intensive medical therapy alone and if it does, will the benefit be clinically meaningful? Cardiovascular Health Study Collaborative Research Group. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. Pickett CA, Jackson JL, Hemann BA, Atwood JE. Race-ethnicity and determinants of carotid atherosclerosis in a multiethnic population. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease.  JM, Webber Sillesen H, Amarenco P, Hennerici MG, et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. Computed tomography angiography (CTA) allows imaging of the carotid arteries from the aortic arch to the circle of Willis with 100% sensitivity and 63% specificity (Figure 2). Chappell FM, Wardlaw JM, Young GR, et al. to download free article PDFs,  MD, Marler The clinical trial that will provide the highest-quality data on this topic is still in progress. Sharrett AR, Patsch W, Sorlie PD, Heiss G, Bond MG, Davis CE. Privacy Policy| Identify all potential conflicts of interest that might be relevant to your comment. Eisenberg RL, Bank WO, Hedgcock MW. O'Leary DH, Polak JF, Kronmal RA, et al. Corresponding Author: Seemant Chaturvedi, MD, Department of Neurology & Stroke Program, University of Maryland School of Medicine, 110 S Paca St, Baltimore, MD 21201 (Schaturvedi@som.umaryland.edu). At 1 year, there was no significant difference in the end point rate between CEA (2.5%), CAS (3.0%), and best medical therapy (0.9%). The 30-day stroke/death rate among both the CEA and carotid artery stenting (CAS) patients was 2.5%. Alvarez-Linera J, Benito-Leon J, Escribano J, Campollo J, Gesto R. Prospective evaluation of carotid artery stenosis: elliptic centric contrast-enhanced MR angiography and spiral CT angiography compared with digital subtraction angiography. Prevalence of and risk factors associated with carotid artery stenosis: the Tromso Study. Conflict of Interest Disclosures: Dr Chaturvedi serves on the executive committee of Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST 2) and Asymptomatic Carotid Trial I (ACT-1) and on the management committee of the CREST 2 registry outside the submitted work. CABG surgery is ideal for individuals with multiple narrowings in multiple coronary artery branches.  et al. Long A, Lepoutre A, Corbillon E, Branchereau A. Conventional catheter angiography is the gold standard imaging modality to which non-invasive imaging techniques have been compared, although its use today is often reserved for cases of diagnostic uncertainty and those in which catheter-based revascularization is planned. Brott TG, Hobson RW, 2nd, Howard G, Roubin GS, et al; CREST Investigators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. In addition, the USPSTF comments on improvement in intensive medical therapy since ACAS. This International journal, Journal of Clinical Neuroscience publishes articles on clinical neurosurgery and neurology and the related neurosciences such as neuro-pathology, neuro-radiology, neuro-ophthalmology and neuro-physiology. Cumulative effects of high cholesterol levels, high blood pressure, and cigarette smoking on carotid stenosis. Crouse JR 3rd, Raichlen JS, Riley WA, et al; METEOR Study Group.  U, Adequate training for stent performers prior to RCTs remains controversial. Individuals with pacemakers and other implants may not be able to undergo MRA. A marker for atherosclerosis in the elderly? Briel M, Studer M, Glass TR, Bucher HC. In NASCET, although stroke and death rates at 30 days were higher in the CEA group than in the non-surgical group, at 2 years CEA patients had much lower rates of stroke (16% vs. 32%). Duplex sonography of the cerebral arteries: efficacy, limitations, and indications. Carotid bruits and cerebrovascular disease risk: a meta-analysis.  VJ, Meschia Patients older than 75 had greater benefit.72 Findings in the MRC European Carotid Surgery Trial were similar, with higher rates of stroke and death in the surgery group at 30 days, but lower rates of stroke at 3 years (12% vs. 22%).70,71. Leonardi M, Cenni P, Simonetti L, Raffi L, Battaglia S. Retrospective study of complications arising during cerebral and spinal diagnostic angiography from 1998 to 2003. Dion JE, Gates PC, Fox AJ, Barnett HJ, Blom RJ. Fine-Edelstein JS, Wolf PA, O'Leary DH, et al. Davies KN, Humphrey PR. The SVS prefers CEA to carotid artery stenting, except possibly in patients younger than 70 years. The Atherosclerosis Risk in Communities (ARIC) Study. In the Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial of patients with carotid atherosclerosis, atorvastatin compared with placebo reduced the risk of stroke by a third and major coronary events by more than 40%.58 Statins also slow the progression of carotid atherosclerosis as measured by IMT.59-61, Current guidelines call for the addition of a bile acid sequestrant or niacin to aid in achieving optimal cholesterol levels, but recent evidence calls the benefit of niacin into question.62,63, It is unknown whether aspirin prevents stroke in asymptomatic patients with CAS.  Comparative effectiveness of carotid endarterectomy vs initial medical therapy in patients with asymptomatic carotid stenosis. , Howard  Screening for asymptomatic carotid artery stenosis in the general population: updated evidence report and systematic review for the US Preventive Services Task Force. , Reiff Stroke 1993; 24:355–361. When the competing risk of nonstroke deaths are included, the benefit with CEA was no longer statistically significant. White H, Boden-Albala B, Wang C, et al.  Endarterectomy for asymptomatic carotid artery stenosis. , Huber Wilson PW, Hoeg JM, D'Agostino RB, et al. Hopefully, enrollment will be completed in 2022. Published online February 02, 2021. doi:10.1001/jamaneurol.2020.5382, © 2021 American Medical Association.  DA, Flynn  M, Hayter Effect of rosuvastatin on progression of carotid intima-media thickness in low-risk individuals with subclinical atherosclerosis: the METEOR Trial. Screening for asymptomatic carotid artery stenosis: a systematic review and meta-analysis for the US Preventive Services Task Force. Clinical events following neuroangiography: a prospective study. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. The accrediting organization for vascular laboratories, recently recommended that laboratories without rigorously validated internal criteria use the SRU criteria.24. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Jahromi AS, Cina CS, Liu Y, Clase CM. When this occurs, cytokine release ultimately leads to monocyte deposition in the artery wall. Smilde TJ, van Wissen S, Wollersheim H, Trip MD, Kastelein JJ, Stalenhoef AF. In endarterectomy, the surgeon opens the artery and removes the plaque. Imaging for CAS includes duplex ultrasound, CTA, MRA, and catheter angiography, but ultrasound is usually the preferred initial imaging modality. Influence of apolipoprotein E, smoking, and alcohol intake on carotid atherosclerosis: National Heart, Lung, and Blood Institute Family Heart Study. Wagenknecht LE, Zaccaro D, Espeland MA, Karter AJ, O'Leary DH, Haffner SM. Screening for asymptomatic internal carotid artery (ICA) stenosis has been a controversial topic for many years. Lawes CM, Bennett DA, Feigin VL, Rodgers A. The Heart Outcomes Prevention Evaluation Study Investigators. Cardiovascular safety of varenicline: patient-level meta-analysis of randomized, blinded, placebo-controlled trials. It found that carotid artery stenting was non-inferior to CEA at one year using the composite endpoint of stroke, MI, or death within 30 days and death or ipsilateral stroke within a year.  Carotid revascularization and medical management for asymptomatic carotid stenosis: protocol of the CREST-2 clinical trials. , Turan HPS2-THRIVE Collaborative Group, Landray MJ, Haynes R, Hopewell JC, et al. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications. Carotid artery stenosis: Gray-scale and Doppler US diagnosis—Society of Radiologists in Ultrasound Consensus Conference. Halliday A, Mansfield A, Marro J, et al; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Mortality and complications increase with: older age, poor heart muscle function, disease obstructing the left main coronary artery, diabetes, chronic kidney failure, and chronic lung disease. The AHA encourages practitioners to consider individual patient factors including life expectancy in determining which asymptomatic patients should be revascularized. Carotid artery atherosclerosis in type-2 diabetic and nondiabetic subjects with and without symptomatic coronary artery disease (The Insulin Resistance Atherosclerosis Study). Accessibility Statement, Our website uses cookies to enhance your experience. Haffner SM, Agostino RD, Jr., Saad MF, et al. Purpose: The purpose of this study was to determine whether the hemodynamic consequences of extracranial carotid disease correlate with the risk of subsequent cerebral infarction.Methods: In 95 patients with symptoms who had greater than or equal to 70% stenosis (31 patients) or who had occlusion (64 patients) of the ipsilateral carotid artery, cerebral blood flow was measured by the … intersocietal.org/vascular/main/links_references.htm, Tight stenosis may be interpreted as total occlusion, Box 2. The major disadvantage is the small risk of stroke, typically less than 1% with experienced operators.38-46, Guidelines issued in 2011 by the American Heart Association (AHA), American Stroke Association, and other bodies recommend DUS as the first-line imaging in asymptomatic patients with suspected CAS or a carotid bruit as well as in those with transient neurologic symptoms that are suspected to be ischemic. The ACAS and ACST trials randomized participants with 60% to 99% stenosis to CEA or aspirin. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), Comparison of 3 Treatment Strategies for Medication Overuse Headache, Association of Stress-Related Disorders With Subsequent Neurodegenerative Diseases, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. Published Online: February 2, 2021. doi:10.1001/jamaneurol.2020.5382.  A, Harrison Reserved.  Angioplasty in asymptomatic carotid artery stenosis vs endarterectomy compared to best medical treatment: one-year interim results of SPACE-2. , Halliday This recommendation is the same for symptomatic patients outside the hyperacute period, but the optimal blood pressure level remains undefined.47. At 1 year, there was no significant difference in the end point rate between CEA (2.5%), CAS (3.0%), and best medical therapy (0.9%). Carotid artery stenosis may be entirely asymptomatic. x Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. For example, in SPACE-2, risk factor frequencies for hypertension, diabetes, and dyslipidemia were 89%, 29%, and 79%, respectively.5. Contrast-enhanced three-dimensional magnetic resonance angiography of atherosclerotic internal carotid stenosis as the noninvasive imaging modality in revascularization decision making.  Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Florida. , US Preventive Services Task Force. Carotid artery stenosis: grayscale and Doppler ultrasound diagnosis--Society of Radiologists in Ultrasound consensus conference. Thickening of the carotid wall. Davies KN, Humphrey PR. Amarenco P, Labreuche J, Lavallee P, Touboul PJ. All patients with CAS should have medical management that includes control of hypertension, cholesterol levels, and diabetes, administration of antiplatelet agents, and smoking cessation. Medical Management of Carotid Stenosis, Addition of bile-acid sequestrant or niacin as needed, Clopidogrel in aspirin-intolerant patients. Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: systematic review and meta-analysis. The Atherosclerosis Risk in Communities (ARIC) Study Investigators. Blood Pressure Lowering Treatment Trialists' Collaboration.  KG, Cuddeback Effect of aggressive versus conventional lipid lowering on atherosclerosis progression in familial hypercholesterolaemia (ASAP): a prospective, randomised, double-blind trial.  EM, Hoggatt After the diagnosis of ICA stenosis, are patients consistently receiving intensive medical therapy? There are many velocity criteria for determining degree of stenosis, some more widely accepted than others. Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: an update of the evidence for the U.S. Preventive Services Task Force. Anderson TJ, Boden WE, Desvigne-Nickens P, et al. Carotid artery stenting can be used for symptomatic patients with the same degree of stenosis and favorable risks for endovascular intervention, when the anticipated periprocedural stroke and mortality rate is less than 6%. Most carotid artery TIAs and strokes occur in the distribution of the middle cerebral artery (MCA), which may lead to contralateral hemiplegia or sensory loss of the lower face or arm and contralateral homonymous hemianopia. Hankey GJ, Warlow CP, Sellar RJ. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. No well-done clinical trial has justified a change in the overall recommendation that routine screening is not warranted. As with ultrasound, it may be difficult to differentiate a sub-total from a total occlusion with CTA and the degree of CAS may be overestimated.31 Images may also be subject to artifact from metal dental work and heavily calcified plaques. Until we can answer these questions, we should focus not so much on screening but instead on the completion of studies that provide meaningful data for shared decision-making between patients and clinicians. The CHS Collaborative Research Group. A small trial was conducted (Stent-Protected Angioplasty in Asymptomatic Carotid Stenosis vs Endarterectomy Study [SPACE 2]5) in which 513 patients were randomly assigned to medical therapy alone or carotid revascularization, but it was halted prematurely because of slow recruitment and loss of funding. Precursors of extracranial carotid atherosclerosis in the Framingham Study. In addition, the USPSTF comments on improvement in intensive medical therapy since ACAS. Preoperative diagnosis of carotid artery stenosis: accuracy of noninvasive testing. Zwiebel WJ. © 2021 American Medical Association. Jonas DE, Feltner C, Amick HR, Sheridan S, Zheng ZJ, Watford DJ, et al. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Mortality rate: 32% Complications: stroke or mini-stroke, narrowing of arteries, and blood clots A narrowed carotid artery must be opened.Otherwise, a patient … Grant EG, Benson CB, Moneta GL, et al. Terms of Use| In 1995, the Asymptomatic Carotid Atherosclerosis Study (ACAS) was published, showing a reduction in ipsilateral stroke among patients with stenosis of 60% to 99% who underwent carotid endarterectomy (CEA).1 This led to a sharp rise in the volume of CEA procedures and calls to screen middle-aged and elderly individuals with no symptoms of a recent transient ischemic attack or ischemic stroke. The AHA guidelines recommend treating hypertension to maintain blood pressure below 140/90 mm Hg in asymptomatic CAS patients.47 In patients with symptomatic CAS who are outside the hyperacute period, blood pressure probably should be treated, but the benefit of treating to a specific target has not been established in relation to risk of exacerbating cerebral ischemia. Sensitivity and specificity of color duplex ultrasound measurement in the estimation of internal carotid artery stenosis: a systematic review and meta-analysis. IAC vascular testing white paper on carotid stenosis interpretation criteria. Nederkoorn PJ, van der Graaf Y, Hunink MG. Duplex ultrasound and magnetic resonance angiography compared with digital subtraction angiography in carotid artery stenosis: a systematic review.  TS, Wheeler Effects of statins on stroke prevention in patients with and without coronary heart disease: a meta-analysis of randomized controlled trials. The Insulin Resistance Atherosclerosis Study (IRAS). In the current statement, the US Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic carotid artery stenosis in the general adult population (D recommendation).3 The evidence report and systematic review4 have also been updated. Similarly, patients with diabetes should be treated to an LDL below 70 mg/dl. Nederkoorn PJ, Mali WP, Eikelboom BC, et al. The Northern Manhattan Stroke Study. AHRQ Publication No. Hankey GJ, Warlow CP, Molyneux AJ. The prevalence of CAS is slightly higher in men than women.4, Hypertension is a strong risk factor for CAS. Djousse L, Myers RH, Province MA, et al. 2021 American Medical Association. Ischemic stroke accounts for the vast majority of strokes, and atherothrombosis of large arteries including the carotids cause about 15% of all ischemic strokes.1 The definition of hemodynamically significant CAS varies from study to study ranging in degree of stenosis from 50% to 70% and greater. Complications of cerebral angiography for patients with mild carotid territory ischaemia being considered for carotid endarterectomy. Distribution and correlates of sonographically detected carotid artery disease in the Cardiovascular Health Study. Previous trials such as ACAS and the Asymptomatic Carotid Surgery Trial6 did not include a consistent protocol for blood pressure control or high-potency statin use.  M, Mohr JP, Thompson JL, Lazar RM, et al; Warfarin-Asprin Recurrent Stroke Study Group. Protected carotid-artery stenting versus endarterectomy in high-risk patients. Selection of appropriate patients for revascularization depends on the degree of stenosis and presence or absence of symptoms. Copyright ©2003 by Radiological Society of North America (RSNA). Sutton-Tyrrell K, Alcorn HG, Wolfson SK, Jr., Kelsey SF, Kuller LH. JAMA Neurol. However, there was a subsequent backlash against the rising volume of CEA procedures when reports emerged that community surgical results did not match the excellent performance of the carefully vetted surgeons in ACAS.2 The antiscreening forces gained momentum with the argument that even if asymptomatic ICA stenosis is identified, it is not clear that real-world CEA performance will improve outcomes. Complication rate and control of risk factors. Associations of lipoprotein cholesterols, apolipoproteins A-I and B, and triglycerides with carotid atherosclerosis and coronary heart disease. Sacco RL, Roberts JK, Boden-Albala B, et al.  et al; CREST-2 study investigators. Not all submitted comments are published. * Plaque estimate (diameter reduction) with gray-scale and color Doppler ultrasound. Rockville, MD: Agency for Healthcare Research and Quality; 2014. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. High-resolution, contrast-enhanced magnetic resonance angiography with elliptical centric k-space ordering of supra-aortic arteries compared with selective X-ray angiography. Complications of cerebral angiography in patients with symptomatic carotid territory ischaemia screened by carotid ultrasound. Risk, causes, and prevention of ischaemic stroke in elderly patients with symptomatic internal-carotid-artery stenosis. Wutke R, Lang W, Fellner C, et al. Similarly, magnetic resonance angiography (MRA) allows imaging from the aortic arch to the brain with sensitivity approaching 100% and specificity of 82% to 95%32-36 and has the advantage of no radiation exposure.37 Contrast-enhanced MRA is superior to non-enhanced MRA in evaluating the carotid arteries but as with CTA, patients with renal insufficiency are not good candidates for contrast-enhanced MRA and MRA may overestimate the degree of stenosis. Singh S, Loke YK, Spangler JG, Furberg CD.  JK, Dame Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons.It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. Wagenknecht LE, D'Agostino R, Jr., Savage PJ, O'Leary DH, Saad MF, Haffner SM. It is unclear whether intensive control of blood glucose can reduce stroke risk, but since it reduces MI risk, it is a part of risk modification for those with asymptomatic and symptomatic CAS. In the Asymptomatic Carotid Surgery Trial, the stroke rate was significantly lower and the benefits of CEA reduced among patients who were prescribed statins. Carotid artery stenosis: accuracy of noninvasive tests--individual patient data meta-analysis. Blood pressure and stroke: an overview of published reviews.  et al. Brott TG, Halperin JL, Abbara S, et al. The 30-day stroke/death rate among both the CEA and carotid artery stenting (CAS) patients was 2.5%. Quantification of internal carotid artery stenosis with duplex US: comparative analysis of different flow velocity criteria. Carotid artery stenosis (CAS), atherosclerotic narrowing of the extracranial carotid arteries, is clinically significant because CAS is a risk factor for ischemic stroke, which affects more than 600,000 American adults each year.